Nepal report sept2014 by Greg Berger

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD-AND NUTRITIONSECURITY IN NEPAL RESEARCH REPORT

Prepared by Another Option LLC September 2014

C O NT E NT S ACRONYMS I EXECUTIVE SUMMARY

CHAPTER I

INTRODUCTION 1

1.1 Background

1.2 Objective of the Survey

CHAPTER 2

STUDY DESIGN AND METHODOLOGY

2.1 Study Design

2.2 Sample Design

2.2.1 Research Population

2.2.2 Gender Representation

2.2.3 Ethnic Representation

2.2.4 Age

2.2.5 Key Informants

2.2.6 Research Location

2.3 Sample and Sampling Strategy

2.4 Research Protocol and Data Collection Tools

2.5 Recruitment and Training

2.6 Data Collection and Analysis

CHAPTER 3

FINDINGS 10

3.1 Values and Aspiration

3.2 Fears and Concerns

3.3 Breastfeeding

3.4 Complementary Feeding

3.5 Source of Information

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

ANNEX

A. ECOLOGICAL MODEL THEORY FOR BEHAVIOR CHANGE COMMUNICATION 27 B. BIBLIOGRAPHY FROM ANOTHER OPTION’S ASSESSMENT REPORT

C. KEY FINDINGS FROM ANOTHER OPTION’S ASSESSMENT REPORT

D. DISCUSSIONS GUIDES (SEVEN ENGLISH-VERSIONS)

ACKNO WL E D G E M E N T S This report was prepared for The World Bank under the Contract 7170122, February – December 2014. Authors of the report are Sumi Devkota and Dee Bennett, Another Option LLC. Research design and field work by Right Direction Nepal and Another Option, LLC. Graphic design of the report is by Greg Berger Design.

NOTE ABOUT TRANSLATION The authors have followed American-English for the spelling of Nepali names and locations and have attempted to be as consistent as possible. In writing and editing this report we found several ways to spell the same word for foods, names, and locations. In editing the document we chose the spelling most commonly used in English.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

AC RO NYM S AHW ANC ANM BCC CBS CMAM DALO DGs DHO EPI FCHV GMP GON HCW HFMC HKI IYCF MCHW MNP NAFSP NID PNC SHD SUAAHARA UNESCO UNICEF USAID VDC VHW WB

Auxiliary Health Worker Antenatal Care Auxiliary Nurse and Midwife Behavior Change Communication Central Bureau of Statistics Community Management of Acute Malnutrition District Agriculture Livelihood Officer Discussion Guides District Health Office Expanded Program of Immunization Female Community Health Volunteer Growth and Monitoring Program Government of Nepal Health Care Worker Health Facility Management Committee Helen Keller International Infant and Young Child Feeding Maternal Child Health Worker Micronutrient Powder Nepal Agriculture and Food Security Project National Immunization Day Post Natal Care Sunaula Hazar Din Program USAID-funded Feed the Future Program United Nations Educational, Scientific and Cultural Organization United Nations Children’s Fund United States Agency for International Development Village Development Committee Village Health Worker World Bank

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

EX EC U T I VE S U M M A R Y The World Bank (WB) continues to support the Government of Nepal’s (GON) thrust to improve the food and nutrition security of its people. It already has several major investments in agriculture and nutrition development programs, including Sunaula Hazar Din (SHD), a Community Action for Nutrition Project, and the Nepal Agriculture and Food Security Project (NAFSP). The World Bank initiated a behavior change communication and social marketing activity that examined the role of gender in correct breastfeeding practices (exclusive breastfeeding) and the proper and timely introduction of complementary feeding, Infant and Young Child Feeding (IYCF). Another Option was selected by the World Bank to design and manage this activity. For its behavior change communication (BCC) the technical team followed an ecological model (originally developed by Green & Kreuter in 1988; updated by Green, Richard, Potvin, Ecological Foundations of Health Promotion, 1996) that reflects individual factors as well as environmental variables (social, political, and cultural norms) that influence the mother and her family (Attachment A). The technical team conducted a wide-reaching assessment of secondary research data from Nepal as well as other countries with similar ethnic populations and social and cultural norms. The team also looked at the government of Nepal’s long-term strategies related to nutrition status and breastfeeding and complementary feeding practices, with a view to mitigating malnutrition and the general poor health of infants and young children. (Attachment B Another Option Assessment Report. Bibliography 2014) The qualitative research aimed to: 1) verify the key findings of the assessment; 2) determine the concerns and aspirations of target audiences – four ethnic minority women, their husbands, and mothers-in-law living in the terai and the hills; 3) use this data to design behavior change communication messages that address the barriers to the adoption of exclusive breastfeeding practices; and 4) identify interventions to encourage and motivate timely implementation of complementary feeding.

INCOMPATIBLE STATISTICS The assessment data showed two statistics that are contradictory. World Bank Data 2011 show 40.5 percent of Nepali children under the age of five suffered from stunting and 29.1 percent were underweight. However, the Mid-term Survey by the Nepal Family Health Project II shows that 90 percent of all women across all ethnic populations said they had breastfed their children (NFHP II. Mid-term Survey. 2010). Clinical research shows that exclusive breastfeeding for six months eliminates or reduces malnutrition, stunting, wasting, and underweight.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

KEY FINDINGS The key fears and concerns that stand out among the study populations from the four ethnic groups (Dalit, Janajati, Madhesi and Muslim) are: lack of employment opportunities, minimum basic health and education services at local levels, and food security (hills). These issues have contributed to the majority of the adult males that are able to work migrating to India or other countries to earn an income, gain financial stability, and create a better life that includes an education for their children. Women (wives and mothers) remain at home, dealing with an overwhelming workload, a sense of isolation, and severe economic conditions. Two other main concerns (fears) expressed by both men and women about their lives are gender and caste inequality. The gender inequality prevails in all castes except Janajati and is manifest in different ways on a regular basis. Child marriage and multiple marriages are high in the terai among Madhesi and Muslims respectively. Mothers are less empowered having left school when they began menstruation or are married young. This means the mothers and mothers-in-law have received less education and have lower literacy levels. A UNESCO 2010 study shows that a child born to a literate mother is 50 percent more likely to survive past the age of five years. Overwhelmingly the mothers, mothers-in-law, and fathers do not understand the critical role and long-term positive affect exclusive breastfeeding and the correct introduction of complementary feeding has on their child’s emotional and physical development. Nor do they make the link between their aspirations for economic stability and a healthy family with their adopting positive actions like exclusive breastfeeding. None of the audiences recognize the financial implications of having malnourished children. World Bank Data (2012) shows outof-pocket expenses for health issues at 41.7 percent, and that expense is increasing annually. These are indications of the gap between what mothers and families want (aspirations) and what they do to achieve them (health practices). Each ethnic population promotes and follow specific social and cultural practices related to breastfeeding. For example, a high percentage of Janajati in Rukum do not feed colostrum to newborns; Madhesi introduce honey and goat milk to newborns during the first few days after birth; Madhesi and Muslims substitute other milk since they believe that mother’s milk does not start for the first two days after birth; and Janajati follow the custom of introducing rice with local wine at about three months of age.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

III

Each of these customs and social norms, or external factors, are deterrents to exclusive breastfeeding and therefore have a direct result to Nepali childrenâ&#x20AC;&#x2122;s wasting, stunting, underweight, and overall malnourishment. Because almost all mothers say they have breastfed (NFHP II statistics report show 90 percentile) family members (husbands and mothers-in-law) are less supportive or understanding of a mother practicing it. The workload for a mother does not diminish after she has a child and exclusive breastfeeding which is time consuming, or preparing special foods (complementary) for the child is seen as a waste of time. Across the ethnic populations animal meats, green vegetables, and fruits that would be used as homemade complementary foods are either not affordable or they are perceived to be indigestible by a young child. Commercial complementary foods are also not easily accessible (not in the shops or markets) even when affordable so low-nutrient foods like biscuits and teas that are readily available in the home are substituted. Parents across ethnic groups identify diarrhea and pneumonia as the health issues they fear most. Hygiene and sanitation conditions are still below acceptable standards throughout Nepal though statistics show an increase of access to water. And, similarly directly related to the aspirations and actions for breastfeeding, the link between hygiene and sanitation and diarrhea and family health is not being made. How the target audiences receive their information and who are considered the most trusted, credible sources of information are important data for designing effective behavior change communication. Local FM radio stations (60 percent) seem to be the most effective mass medium to reach our target audience followed by interpersonal communication among family and friends (50 percent) and Female Community Health Volunteers (FCHV)/influentials (30 percent). Whereas the most trusted sources for health information reportedly are doctors/FCHVs (80 percent), traditional healers (60 percent), family and community leaders (50 percent) and FM radio station (30 percent). Though internet service is still nominal (6 percent) especially in the hills, 71 percent of Nepalese subscribe to a mobile service.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

C H A P T E R

I NTR O D U CT I ON 1.1 BACKGROUND The Government of Nepal and its development partners including the World Bank are committed to improving food and nutrition security in Nepal in order to reduce malnutrition, stunting, wasting and the general poor health status of infants and young children. World Bank has made major investments in Nepal in two agriculture and nutrition programs Sunaula Hazar Din, (SHD), a Community Action for Nutrition Project, and the Nepal Agriculture and Food Security Project, (NAFSP). The World Bank also initiated a behavior change communication and social marketing activity that includes the role of gender in breastfeeding and Infant and Young Child Feeding (IYCF). The overall objective of all of these programs is to have healthier Nepal citizens. Another Option was selected by the World Bank to design and manage this activity. The behavior change communication (BCC) approach followed an ecological model (originally developed by Green & Kreuter in 1988; Green, Richard, Potvin, Ecological Foundations of Health Promotion, 1996) that reflects individual factors as well as environmental variables (social, political, and cultural norms) that influence the mother and her family. The technical team conducted a wide-reaching assessment of secondary research data from Nepal as well as other countries with similar ethnic populations and social and cultural norms. As part of the assessment the team looked at the government of Nepal’s long-term strategies related to nutrition status, breastfeeding and complementary feeding practices, with a view to mitigating malnutrition and the general poor health of infants and young children (Attachment B. Another Option’s Assessment Report. Bibliography. 2014). Data from the IYCF strategy reveal that: 66 percent of babies are introduced to complementary feeding at six to eight months; 79 percent are receiving minimum meal frequency; and a low 29 percent have a diverse diet. Existing data from a wide-range of studies show extremely high percentage (over 90 percent) of women across several ethnic groups saying they breastfeed their babies, however only 30.6 to 47.3 percent admit to early initiation of breastfeeding (Attachment C. Another Option’s Assessment Report for the World Bank. Child and Maternal Nutrition Status and Ethnicity. March 2014). It may be argued that if correct breastfeeding behaviors were that high even if not optimally observed the prevalence of stunting, wasting, under-weight and malnutrition among Nepal children would be lower. Instead, these nutrition deficiencies remain extremely high, especially among lower socio-economic and ethnic groups. A key finding is that conventional wisdom across audiences and populations ranging from political and community leaders to other influentials to husbands/fathers, mothers-in-law, and mothers is that “everyone knows about breastfeeding.” However, the reality is what they

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

do know are the fundamentals of breastfeeding, i.e., how to breastfeed. This knowledge is then augmented with cultural and social practices that are specific to their ethnic population. Too often these practices run counter to exclusive breastfeeding and correct complementary feeding. Examples of cultural and social practices that distract from exclusive breastfeeding are evident are: • Janajati in Rukum do not feed colostrum to newborns • Madhesi introduce honey and goat milk to newborns during the first few days after birth • Madhesi and Muslims substitute other milk because they believe mother’s milk does not start for the first two days after birth • Janajati follow the custom of introducing rice with local wine at about three months of age. Each of these customs and social norms, the external factors, are deterrents to exclusive breastfeeding which contribute to Nepali children’s wasting, stunting, underweight and overall malnutrition.

1.2 OBJECTIVES OF THE RESEARCH The objectives of the qualitative research were to 1) verify the key findings of the assessment; 2) identify the concerns and aspirations of the target audiences – ethnic minority women, their husbands and mothers-in-law; and 3) to use this data to design behavior change communication messages that reduce barriers preventing adoption of correct breastfeeding practices and encourage and motivates timely implementation of complementary feeding. The research was designed to identify the following: • The aspirations and concerns of our audiences across ethnic, cultural, and social groups that may be barriers to exclusive breastfeeding • The communities of practice that influence and support mothers and their infants • Social, cultural and political norms (external factors) that may prove to be the barriers or deterrents to correct behaviors (exclusive breastfeeding) especially for the targeted socioeconomic groups and ethnic populations • Constraints or opportunities to maximize IYCF practices among these same socioeconomic and ethnic audiences

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

C H A P T E R

STUDY DESIGN AND METHODOLOGY 2.1 STUDY DESIGN There were two components of the research: qualitative analysis of key audiences (mothers, fathers, mothers-in-law, and influencers in the community), and a market assessment of IYCF. The qualitative research took a consultative and participatory approach. Identification of the source and nature of these influences as well as real or perceived barriers involved targeting both the primary audience – mothers of children under 24-months, husbands, and mothersin-law across majority Nepali and minority ethnic groups – and secondary audiences comprised of friends (peers) and influentials. The qualitative research determined the aspirations and dreams and the concerns and fears of the mothers and the linking of these to their adopting correct health practices. The market assessment of IYCF comprised a combination of observational research and interviews with vendors, e.g., shopkeepers, pharmacists, distributors. The social marketing component of this task helped verify the availability, accessibility, acceptance, and approval of commercial and subsidized complementary feeding products among the primary audiences.

2.2 SAMPLE DESIGN 2.2.1 Research Population The primary population for this research included mothers of children under 24-months, fathers and mothers-in-law from four selected minority and majority ethnic populations living in the terai and the hills. The research included secondary audiences of community health care providers, educators and religious and community and private sector leaders.

2.2.2 Gender Representation The research covered both male and female primary and secondary respondents. Among females, the primary study populations of this research were pregnant women, mothers of children under 24-months and mothers-in-law. The males in the study were fathers. The field team from each study district also ensured gender balance among secondary respondents, i.e., health care providers, religious leaders, community leaders, business leaders, educators, civil society and model farmers.

2.2.3 Ethnic Representation The different ethnic groups of Nepal were represented in the research. The primary respondents were mainly from four ethnic groups: Dalit, Janajati, Muslim and Madhesi whereas the other ethnic groups were covered in the secondary set of respondents.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

2.2.4 Age Mothers were classified into three groups: pregnant women, adolescent mother, and adult mother above 24 years of age to ensure coverage of the age range among primary respondents. In addition, older women were captured as mothers-in-laws. The husbands of the three groups of mothers were also included. These arrangements allowed for representation of all relevant age groups.

2.2.5 Key Informants Key informants included health workers, health facility management committee members, school management committee representatives, religious leaders, community leaders, the media, civil society, private sector, mobile carriers and shop owners.

2.2.6 Research Location The district sample frame for this research was the districts of the World Bankâ&#x20AC;&#x2122;s two projects: NAFSP and SHD. NAFSP covered 19 districts of the mid- and far-west development hill region (Dolpa, Humla, Jumla, Mugu, Kalikot, Pyuthan, Rolpa, Rukum, Jajarkot, Salyan, Surkhet, Dailekh, Darchula, Bajhang, Bajura, Baitadi, Dadeldhura, Doti and Achham). SHD covered 15 districts of the central and eastern hill and terai (Makwanpur, Sindhuli, Ramechhap, Udayapur, Khotang, Okhaldhunga, Parsa, Bara, Rautahat, Sarlahi, Mahottari, Dhanusha, Sira, Saptari and Sunsari). Four hill districts (Bajhang, Achham, Rukum and Sindhuli) and four terai districts (Parsa, Rautahat, Dhanusha and Sunsari) were selected for the research; five from SHD and three from NAFSP. Selection of research districts was based on concentration of targeted ethnic groups and geographical diversity. The research investigated Janjati ethnic group from Sindhuli, Rukum and Sunsari districts; Dalits were covered from Bajhang and Achham districts. Similarly, with respect to terai ethnic groups, Muslims were covered from Parsa, Rautahat and Sunsari districts whereas Madhesi were interviewed in Parsa, Rautahat and Dhanusha districts. Two Village Development Committees (VDCs) from each research district were selected depending on the higher concentration of a specific ethnic group (Dalit, Muslim, Janjati and Madhesi) in the district. Available Central Bureau of Statistics (CBS) 2011 data were used for selection of the VDCs. The ethnic group targeted for investigation was located upon reaching the VDC.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

2.3 SAMPLE AND SAMPLING STRATEGY Initially, a list of pregnant women and mothers of newborn children below two years old in that community was prepared with the help of Female Community Health Volunteers (FCHV). Separate sample frames of eligible mothers (pregnant mother, adolescent mother, adult mother) of the targeted ethnic group were developed from that list; these were requested to participate in the research process. The list of fathers and mothers-in-law was similarly developed and they too were invited to participate in the research. Maternal Child Health Workers (MCHWs)/Auxiliary Nurse Midwifes (ANMs) were selected as the health workers from SHPs/HPs of the identified VDC to be contacted for in-depth interviews. In their absence or unavailability, s/he was substituted with the person in charge of the health facility or Village Health Worker (VHW). The SHPs/HPs were contacted to obtain the list of FCHVs in the selected VDC. The FCHVs residing in the research location were requested to participate in the study if s/he were unavailable the FCHV in the list was requested. In the case of traditional healers, the most popular recommended by the ethnic group were interviewed. Similarly, a representative from Health Facility Management Committee, School Management Committee and most influential religious leader of the ethnic group were requested for interviews. In-depth interviews of community leaders (mukhiyas, manyanjans, respectable community persons) from each ethnic group were conducted, as appropriate. Two media personnel, one each from the electronic and print media in each district, were interviewed. Moreover, additional stakeholders such as a representative of the Ward Citizen Forum, Nutrition and Food Security Steering Committee, District Agriculture Livelihood Officers or Dalo (agriculture and livestock) and model farmer were interviewed as appropriate.

2.4 FIELD RESEARCH TIME PERIOD The research was conducted from May to June 2014.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

Table 1 Target Audience and Sample Size in Hill Districts

Audiences

Bajhang

Achham

Rukum

Sindhuli

Women with children 24 months and under (Dalit, Janajati, Muslim, Madhesi)

Husbands (Dalit, Janajati, Muslim, Madhesi)

Mothers-in-law (Dalit, Janajati, Muslim, Madhesi)

Health care workers/FCHV, Pharmacists, Traditional healers

Health Facility Management Committee, School Management Committee, Religious Leaders

Community leaders

Media

Additional Stakeholders – Civil Society, Shop Owners, Private Sector

Shop Observation

Total

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Table 2 Target Audience and Sample Size in Terai Districts

Audiences

Parsa

Rautahat

Dhanusha

Sunsari

Women with children 24 months and under (Dalit, Janajati, Muslim, Madhesi)

Husbands (Dalit, Janajati, Muslim, Madhesi)

Mothers-in-law (Dalit, Janajati, Muslim, Madhesi)

Health care workers/FCHVs, Pharmacists and Traditional healers

Health facility Management Committee, School Management Committee, Religious leaders

Community leaders

Media

Additional Stakeholders – civil society, private sector, shop owners

Shop Observation

Total

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

2.4 RESEARCH PROTOCOL AND DATA COLLECTION TOOLS On completion of the pre-assessment report, core research team members developed the research protocol and research tools in English. These were translated in the local language and dialects, pre-tested, revised and finalized accordingly.

2.5 RECRUITMENT AND TRAINING Thirteen field researchers (nine females and four males) were recruited for data collection. They were trained for five days utilizing the training manual developed by the core technical team members. The training included both classroom and field training. The curriculum covered: background, content, purpose and objectives of the study; research tools â&#x20AC;&#x201C; in-depth interview guide, observation checklists to be used for data collection with different categories of respondents; and an explanation of the Discussion Guides (DGs) and their links with the research objectives. Nutrition and research experts from Another Option and Right Direction Nepal (RDN) conducted the two-day classroom sessions to clarify all aspects and areas of the enquiry with the entire research team members responsible for the successful completion of the research. The third day was devoted to field training followed by pretesting of tools, which took place in Bhumi Dada Village Development Committee (VDC) ward number four of Kavrepalanchock district. Each field team member conducted an in-depth interview with the primary audience, another with the secondary audience and one key informant interview with shopkeepers. All interviews took place under the guidance of the supervisors. Thereafter, a review meeting was held with field team members to share field experiences and lessons learned. The interviewers commended the remarkable learning experience, expressing confidence in their ability to undertake the interviews as intended. The core team discussed in detail the feedback on the tools and the comments received from the field staff as well as observations from supervisors that monitored the pre-test process. Inputs and suggestions were noted and the tools were modified based on pre-test results. However, the modifications were not significant; only the sequence of the questionnaire was revised and some minor language changes were made for logic and appropriateness. Field team members were reoriented in the revised tools before their departure to the field. Mock call interviews and discussions were conducted and issues were shared and clarified with all field researchers.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

2.6 DATA COLLECTION AND ANALYSIS The recorded interviews were transcribed verbatim in Nepali language and the transcripts reviewed by core research team members to ensure quality of transcription. The core team members developed major themes and sub-themes and they were elaborated as appropriate by reviewing the major research questions and transcriptions. Each transcript was carefully read, with researchers looking for particular patterns, themes, concerns or responses posed repeatedly by the participants. Similar major themes were further merged under a single primary theme narrowing them down to a feasible number. If needed new themes were created. Color coding was applied by coders in close consultation with core team members to differentiate themes and ensure the consistency of information and association under defined themes and sub-themes. The multiple coders/experts were properly oriented on the objective of the research, data collection tools, themes and sub-themes before data coding and entry. Text and information were reviewed rigorously to ensure accuracy in identifying the link and connection of the responses with the defined themes and sub-themes.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

C H A P T E R

FI ND I NGS 3.1 VALUES AND ASPIRATION The key driving aspirations for the four ethnic groups are the desire for improved livelihoods and a better lifestyle. They yearn for the enhanced opportunities afforded by internal and foreign travel. One of the more remarkable observations during this study was the absence of males from the communities. Entire villages are almost devoid of males, most of the men are in the Gulf States, India or urban areas in Nepal working to earn a living for their families. Their remittance provides the basic necessity and financial stability for the rest of the family back in Nepal.

“I want to work hard so that my family can have good food, my children grow healthy and I can have a small house and buy some land to do some agriculture” – Father from Achham Almost all mothers accord a high value to their children’s education. They believe that a sound education is a passport to a much more rewarding, more stable life. An education would help them secure better employment than their fathers’. They therefore aspire to send their children to private schools. This sentiment is repeated by mothers-in-law also. Mothers want their children to become doctors or engineers since these are among the most respected professions in Nepal. The following quotes of mothers from three different ethnic groups and regions highlight the similarity of their aspirations for their children.

“I want to educate my children and make them prosperous like doctors and engineers are.” –Janajati mother from Sunsari “I want to make my son a doctor.” – Madhesi mother from Parsa “If my husband earns well, I have a dream of providing good education and making him [her son] a doctor.” – Dalit mother from Achham district

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

“I have a dream of making my baby a doctor.” —Dalit mother from Bajhang district Women left their homes to work to earn income. Men left home seeking better opportunities. In their discussions about family aspirations, fathers, mothers and mothers-in-law made no connection between the “value” or health benefit of correct (exclusive) breastfeeding practices and their aspirations for themselves and their children, i.e., education, success, security. The economic impact of having sick children and babies because of malnutrition due to incorrect breastfeeding practices is not understood among these communities. They fail to appreciate the extent of the future health burden their families will experience resulting from under nutrition in early childhood. The World Bank’s Database (Nepal, 2012) shows the outof-pocket expenses for health-related issues at 41.7 percent. It has been increasing annually. The audiences are unaware of the small “doables” that are within their ability to do that will help to reduce these expenses and assure healthy developed children. These doable actions also can significantly contribute to their reaching their aspirations.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

3.2 FEARS AND CONCERNS Most fears and concerns are related to the uncertainty of their livelihood, economic and financial insecurity, or societal marginalization. Most of these concerns are attributable to social, political and cultural norms that limit their educational opportunities, access to quality healthcare, and are derived from overall caste and gender bias including social exclusion.

“One of the concern in my life right now [is] my children’s don’t go to school, are unwell at times, how will they grow, when will they grow up when to educate them, when to send them to school, I keep on thinking about when will they grow. Right now we do not have anything, we are very poor, and we don’t even know if we may be able to educate them, I see people sending their children to school. Rich people send their kids to boarding school, I think I might not even be able to send them to government school, we don’t have money. I keep on thinking about how and what to educate them” – Mother from Dhanusha All four communities, especially the hill region Dalits, are concerned about food and nutrition insecurity in all its dimensions – unavailability, inaccessibility, unaffordability and instability. Dalits and Janjatis are frustrated by having to work in the fields approximately 18 hours a day with only an annual harvest that produces a food supply for less than two months. Janjatis in the past have been affected by flood damage to crops and inadequate markets.

“I have no food at home. I have a child. I wait outside my neighbor’s house so that she will give me the left over and I can feed my child and if something is left, myself too” – mother in Bajhang Men are worried about the inability of finding employment without going outside the village where there are better income-earning opportunities. Lack of skills and education create difficulty in finding decent paying employment. Men also recognize that their lengthy and frequent absence from home is a source of grief, anxiety and sadness, especially to their wives. Many wives echo the desire to have the family living together; at the same time they wish their husbands earn a decent income. This poses a dilemma, since good job opportunities in their communities are rare.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Education – access, quality and universality – is another major concern among all the ethnic groups. Gender bias in providing education is seen as more pronounced in Muslim, Madhesi and Janjati communities. Fathers told the researchers that they are eager “to get rid of their daughters” and that since young brides require smaller dowries, this is an economic incentive for early marriage. More highly-educated females meant parents must find a more educated groom, requiring a larger dowry package. The practice of child marriage is more common among Madhesi and Muslim communities and rare in Janjati and Dalit populations. There is also the practice of multiple marriages which is prevalent in the Muslim community; estimated to be common in about 25 percent of the Muslim community.

“In this community almost 25 percent of males have married more than once and if men earn more money they tend to marry more and also when the wife is not obedient toward their husband.” —School Management Committee member, Muslim community In the terai region, quality higher education is only available in larger, more distant towns and therefore inaccessible and unaffordable. Additionally, Dalits seeking higher education in larger towns, face discrimination to obtain accommodations. Health and health care – accessibility, affordability and quality - are a concern to all communities. Children’s illnesses – diarrhea and pneumonia – are a source of worry to parents. The gender of health care providers is sometimes an issue especially in Muslim communities. All four communities are worried about the unbudgeted expenses that arise when family members fall ill. Terai Muslims prefer to visit health facilities in distant towns or India and they worry about the cost of the travel and treatment. For the Dalits and Janjatis the traditional healers are very influential. These populations express concern about the inadequate service in the health posts and unavailability of the right medicines. Therefore, they prefer going to the pharmacist which means incurring higher costs and longer travel. Women are concerned that they have a limited or no role in decision-making. They worry too about rejection for being seen as acting differently or going against traditionally held beliefs (especially relevant to breastfeeding and complementary feeding practices). The women’s excessive work load reduces the time for child and mother care. These mothers also feel they are in no position to complain. In Muslim communities, daughters-in-law are not generally supported by their mothers-in-law and even husbands. Generally, they are not allowed to work outside the home – rigorously adhered to in Muslim and Madhesi communities, less so in Janjati community. 14

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Verbal and physical abuse of women is still prevalent in the Dalit community especially when men are drunk. It was observed in one interview, when the mother-in-law was in the room, the mother did not respond to the questions and gestured quietly about the mother-in-law being in the room. Dalit mothers in hill regions are concerned about having to walk a long distance to fetch clean water to use for drinking and cooking. They complain about the difficulty in maintaining personal hygiene, having to go all the way down to the river for a bath or to wash their clothes. These same hygiene concerns apply to their caring for their children. Washing and cleaning of their children took a lot of time and energy. The interviewers observed incidents where the children suffered significant skin problems. In the terai region, it is generally easier to produce ingredients for preparing complementary foods from home garden and farming. However, there are real concerns about excessive rains and flooding in the monsoon season that impact food production and loss of livelihoods.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

3.3 BREASTFEEDING A key finding is the observation that the presumed knowledge about the value of breastfeeding has not resulted in correct breastfeeding behavior. The study indicates a high-level of familiarity with breastfeeding but that each ethnic group introduces its own customs and practices as well as interpretation of what and how to breastfeed correctly. There is high frustration among mothers and mothers-in-law with breastfeeding. Common comments included: takes up too much time, it is painful, baby does not want it, and there is little or no milk. There is also tension between health care workers and mothers: “mothers won’t listen” and “they think they know everything” are common complaints by health workers. Messages and training has focused on the “how” of breastfeeding. Most mothers interviewed could recite perfectly the cultural practices specific to their community. They could not relate the value of breastfeeding to their long-term aspiration for their children’s life to be better. Nor did family members understand that breastfeeding could minimize health expenses now and as children grew older or that compromises made in breastfeeding practices could contribute to health issues later on. The Madhesi community feed babies honey and goat milk because there is a general belief that mothers do not produce milk for the first two days following birth. There is a strong belief in the Madhesi community that goat milk is more nutritious than mother’s milk. Similarly a Dalit mother expressed her fear of giving colostrum to a newborn for fear of adverse effects, because that is the general belief in the community. A traditional healer from Janjati community said “the first milk is dirty, that affects the newborn as well, so it is better to throw this away, then to feed the child”. Mothers also experience the constraint of not producing enough milk for babies because of their state of ill-health. The women are concerned about being marginalized for acting differently or going against traditionally held beliefs. This is especially an issue when the husbands are working outside Nepal and the wives feel they do not have any support. The heavy workload in the house reduces the time and space to breastfeed the child at regular intervals. Mothers have to leave home for work, leaving the babies behind and therefore could not continue to exclusively breastfeed. In the Janjati community, the child is given few drops of alcohol along with cooked rice water within 15 days of birth to reduce their crying when mothers were out at work.

“My baby breastfed for three months, then I got pregnant again, the milk production became low so I stopped” – mother from Muslim community

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Mothers in Janjati, Dali, and Muslim community said that they should not breastfeed their baby if they fell ill because they believe that the baby would be infected. Studies conducted by UNICEF and UNESCO repeatedly show the correlation between girl education and adopting positive health behaviors. Health care workers point out that it is easier to convince an educated mother to practice exclusive breastfeeding. There is also a perception that if the daughter-in-law goes outside of the home, she will be influenced by others and that is strongly discouraged.

“If she meets different people, she might get influenced by them which might lead to uncomfortable situation at home” – a Madhesi mother-in-law expressing her thoughts This fear has resulted in mothers not participating in meetings or programs that could raise awareness on breastfeeding as well as other health-focused activities. There is a practice propagated by a segment of fathers, mothers-in-law and health workers to introduce water when exclusively breastfeeding – in some cases as early as the third day. In addition to the exclusive breastfeeding taboo, the purity of the water being given to infants is in questions so the positive benefits of breastfeeding could be compromised by using unclean water. Impure water is a leading contributor to diarrhea. This research shows the two biggest health concerns of mothers for their children are diarrhea and pneumonia. Mothers and families reportedly do not make the connection between exclusive breastfeeding, introduction of impure water, and diarrhea.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

3.4 COMPLEMENTARY FEEDING The first complimentary food that is introduced when children are six months or even earlier is usually not nutritionally adequate. In the terai region where shops are more accessible, they usually start with biscuits and horlicks. Mothers claim that they provide biscuits on the advice of some doctors, so they are convinced that this best for the babies. The mothers say that the babies prefer the taste of biscuits. The mothers also claim that the infants do not like the taste of homemade complementary foods (lito) or dal bhat (rice and lentil) when compared to the biscuits so it is easier to feed them biscuits. It also is less time consuming to prepare the biscuits than other homemade foods. Sometimes babies suffer diarrhea when fed lito for the first time, so the mothers believe it is not good for babies. Another reason that the mothers do not mention is that lito which is made with water may have been prepared with contaminated water that contributed to the child being ill. Commonly used complementary foods are either homemade ‘sarvottam pitho’ or commercial foods like Cerelac made in India or the commercial sarvottam pitho made in Nepal. Soy, wheat, grams, rice and maize are the most commonly used ingredient in these products. The ingredients are roasted, grounded and then stored. This mixture can be eaten directly without recooking but mothers usually roast them again, mix them in sugar and water and feed the mixture to the babies. On the other hand, the commercial preparations are just mixed with water, tea or milk and given to the babies. The commercial foods, when available, are very expensive but generally are inaccessible. They are very seldom used in the hills. In the terai, even though accessible, they are unaffordable to most. One shopkeeper in Rukum and two in Sindhuli explained that most people prefer to buy the expired commercial complementary foods or those very close to the expiration date because they are less expensive. Other cooked complementary foods given to babies include, jaulo (rice and lentil cooked together), mad (adding water to rice), halva (mostly using semolina) and khichdi (prepared by adding water in rice). Mothers admit having limited knowledge about preparing special recipes for children using locally available ingredients. The biggest key constraint, explained by the mothers, is the time it takes for food preparation. This is especially difficult where time is already limited by other responsibilities. The mothers have limited knowledge about the importance of good complementary feeding for children’s growth and development. Twenty-nine percent of Nepali babies have access to a diverse diet. The majority of babies do not eat a variety of foods or from all the food groups, i.e., grains, roots and tubers, legumes and nuts, green vegetables, animal source foods and fruits that are generally available. They are usually feed dal bhat (lentil and rice) with some potatoes. In the terai, Madhesi mothers complained that the babies do not like the taste of the available vegetables like spinach, lady

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

finger, beans explaining “they are not tasty”. They maintain the babies only like the potatoes. Animal products and fruits are neither affordable nor accessible. Additionally, family members indicate that the animal products and fruits are not digestible by babies. The children in the community often suffer from diarrhea when served meat so they were not convinced about the value of giving to their children. In the case of a Dalit community in the hills, the mothers said that in the absence of rains there is no water to grow vegetables and they could not afford to buy vegetables.

“I sprinkled the micronutrient powder in the dal bhat and gave it to my child but he did not like the taste and vomited all the food – I have stopped giving it” —Dalit mother There seems to be inadequate knowledge of using the micronutrient powders (MNP). One of the observations made by the interviewers is that most of the time mothers are very busy and often babies are fed by other members of the family. There is very little interaction with the child during feeding to teach and stimulate social development as well as encourage the child to eat. Dalit women from Bajhang remembered her husband’s word “the cattle are running, there is no grass for the cows, hurry up, you don’t have to spend the whole day feeding the child.” They do not understand the value of or have the luxury of time to practice responsive feeding. This practice helps a child to develop good eating habits and also helps the mother to recognize what her child likes to eat. Another observation was the minimum practice of good hygiene while feeding the child. Feeding is often done outside the house with flies sitting on the babies’ food and face. In addition, mothers rarely wash their hands before feeding the babies. Utensils are dried in the open and are covered in flies. These utensils are not washed again using clean water before feeding the child. Mothers were surprised when interviewers spoke about the relationship between malnutrition and hygiene and sanitation. They only link malnutrition with food intake.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

3.5 SOURCE OF INFORMATION A large proportion of husbands and fathers work overseas, particularly in India. In some populations, the Dalit, their wives and families visit them there. Sometimes, the men return with ideas and opinions that reflect their exposure to different ways of living. Though being away causes hardship – some households are totally dependent on this income to buy essentials including food. A key benefit is better access to information and exposure to practices that enhance their aspirations for their lives and their children. Fathers talked about traveling to India to receive better health care and return with medicines and have had exposure to complementary foods. The health workers and FCHVs provide information on maternal health, family planning and breastfeeding to mothers during Antenatal Care (ANC), delivery and neonatal periods. They provide information on complementary feeding during Post Natal Care (PNC), Expanded Program of Immunization (EPI) and Growth Monitoring Program (GMP). The mother receives generic messages but no counseling is given based on the practices and barriers of the specific community regarding the above health related matters. Also, mothers would receive generic information during the mother’s group meetings that are conducted every month in the community by the FCHVs, if they are allowed to attend. Some health workers expressed frustration in their interventions because the women are just unwilling to listen to what they have to say. In such situations, they try to convey the same messages through the FCHVs at their monthly mothers’ group meetings. Usually, these meetings focus on three topics: health, nutrition and immunization. Health workers receive training in several areas at the District Health Hospital. The DHO always organize training sessions on any new topic being introduced. They have received training in the areas of nutrition, breastfeeding, complementary foods and on CMAM. ANMs have received very useful training from SUAAHARA the USAID-funded Feed the Future Program. It has helped them to understand the importance of breastfeeding and complementary feeding for babies.

“The trainings are very useful and our messages to the mother are gradually working. They have the mothers’ breastfeeding babies right after birth. In addition, newly delivered mothers are bathing within 24 hours after the delivery” The terai has and continues to have a strong influence from India. Additionally, Nepali and Indian media sources provide access to a wide-range of popular culture, health news, and information on personal care. Mass media channels, web-based (internet) communication, and social media are pervasive in the terai but less common in the hills. Though the hills have been and continue to be less connected, villagers do have access to mobile phones. Data from 2011 show 71 percent of Nepali’s have mobile phone subscriptions.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Local FM stations (60 percent) seem to be the most effective mass medium to reach the target audience followed by interpersonal communication with family and friends (50 percent) and FCHVs/influentials (30 percent). Whereas the most trusted sources for health information were doctors/FCHVs (80 percent) followed by traditional healers (60 percent), then family and community leaders (50 percent) and FM station (30 percent). Radio is the most prevalent mass media communication channel in the hills. In the terai, social media is prevalent as well as videos and internet for instruction, information, and entertainment. The local FM is a very popular radio program and mothers get many health messages from them. The research shows that the village mukhiyas and manyanjans are influential and the traditional healers are visited more often than health workers. They also have a high trust level (60 percent) by the families. At the household level across the population it is generally the mother-in-law who makes decisions about complementary feeding. Fathers see their roles more as bread winners and do not interfere in breastfeeding or complementary feeding matters.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

A N N E X

E C O L O G I C A L MO D EL TH EOR Y FO R B E HAV I O R C HA N G E C OMMU N ICATION Audiences – Gender Equality Nutrition in Nepal

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

A N N E X

B I B LIO G R AP HY FR O M AN O T HER OP TION ’ S AS S E S S M E N T REP OR T This bliography is for the principle secondary research Another Option reviewed as part of its assessment to design the qualitative research for the World Bank’s activity, Gender Equality and Social Inclusion for Food- and Nutrition-Security in Nepal. 2012 UNICEF Report: “Analysis of trends in nutrition of children and women in Nepal” Jennifer Crum, MPH, John Mason PhD, Paul Hutchinson, PhD; Tulane University, School of Public Health and Tropical Medicine Alive and Thrive Project www.aliveandthrive.org Ecological Foundations of Health Promotion (1996). Lawrence W. Green, Lucie Richard, and Louise Porvin. American Journal of Health Promotion: March/April 1996. Volume 10, No. 4, pp. 270-281. Family Planning, Maternal Newborn and Child Health Situation in Rural Nepal: A Mid-term Survey for Nepal Family Health Program (NFHP) II (2010) Gender, caste, and ethnic exclusion in Nepal: Following the policy process from analysis to action. 2006 Lynn Bennett, The World Bank. Government of Nepal, Department of Health Services (DoHS), (2012-13). Annual report of department of health services Joshi, N. et al. (2012). Multivariate analysis of main determinants of non-optimal complementary feeding, using 2006 DHS data Karkee R, Jha M, (2010). “Primary health care development: Where is Nepal after 30 years of Alma Ata Declaration?” Kenda Cunningham, Suneetha Kadiyala, (2013). Summary SUAAHARA baseline survey report Linkages Project website (www.linkagesproject.org) Mathur S, Malhotra A, Mehta M. Adolescent girls’ life aspirations and reproductive health in Nepal

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

MoHP (2013). Health sector strategy for addressing maternal under nutrition 2013 – 2017 NPC, CBS, WFP, WB, US AID, UNICEF, (2013). Nepal thematic Report on Food Security and Nutrition Nepal Household Survey, (2012). Nepal Health Sector Program II. Dr. Suresh Mehata, Dr. Sushil Chandra Baral, et al. Patel, Archana, Dr., Dhande, Leena, Dr. (2011). “The Evaluation of the Effectiveness of Cell Phone Technology as Community Based Intervention to Improve Exclusive Breast Feeding and Reduce Infant Morbidity”, mHealth Summit (January 2012). Review of Policy, Strategy, Program interventions and Evidences for Reducing Health and Nutrition Inequities (Draft), 2014. Save the Children. Right Direction Nepal (2012) Formative research on strengthening access and utilization of immunization services in eight terai districts of Nepal Rich Magnani, Anahit Gevolgyan Kathleen Kurz, (2012). Market analysis of complementary food in Nepal (NCRSP 2012) Socio-demographic Features of Mothers in Relation to Duration of Breastfeeding in Manipal Teaching Hospital, Pokhara, Nepal, (2012). Basnet, S., Gauchan E., Malla K., Malla T., et al Singh, J. Kathmandu Academy for Educational Development, (1998). Literature review of the practices and beliefs regarding maternal and infant/child nutrition in Nepal SUAAHARA, USAID (2013). Formative research Report (SUAAHARA) UNFPA, HERD, (2013), Perception Survey 2013 Health Sector Strategy for Addressing Maternal Under-Nutrition in Nepal (2013-17) Food Utilization practices, beliefs and taboos in Nepal an overview – Dr. Ramesh Kant Adhikari May, 2010 Formative Research Report/SUAAHRA/USAID – February 2013 Multisectoral Sectoral Nutrition Plan for Nepal – February 2012 Accelerating Progress in Reducing Maternal and Child Undernutrition in Nepal – Karen Codling, World Bank Consultant – June 2011 Strategy for Infant and Young Child Feeding in Nepal (2013-2017)

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Nepal Nutrition Assessment and Gap Analysis (2009) Understanding the Access, Demand and Utilization of Health Services by Rural Women in Nepal and their constraints – World Bank - June 2001 University of Tampere /School of Health Sciences Situ K.C: Women’s Autonomy and Maternal Health Care Utilization in Nepal; Master’s Thesis Learn and Sharing Series 2 – HELVETAS: Empowering Women

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

A N N E X

KE Y F I N D I N G S FR O M AN O T HER OP TION ’ S AS S E S S M E N T REP OR T Key Findings from Desk Review and Secondary Research AssessmentAnother Option’s Assessment Report, March 2014 for The World Bank The information illustrated below were collected from the various secondary research and documents available with a primary desk review and are categorize by different themes that may be relevant to the qualitative study.

VALUES AND ASPIRATIONS STUDY/REPORT

FINDINGS

Baseline Survey SUAAHARA 2012

These are the findings of economic events which may be associated values and aspirations; Educational scholarship for a child 26 percent and new or increase in remittance 13.1 percent are two most common positive economic events followed by new job of household member 5.3 percent.

Adolescent Girls’ Life Aspirations and Reproductive Health in Nepal

Study shows that adolescent girls in these communities have dreams and aspirations for a better future and adults acknowledge and support these ideals. However, social norms and institutions are restrictive, especially for girls, who are often unable to realize their hopes for continuing education, finding better-paid work or delaying marriage and childbearing, and this directly impacts reproductive outcomes. Urbanization and remittance income have become drivers of poverty reduction and improved nutrition and food security

Nepal Thematic Report on Food Security and Nutrition 2013

The proportion of female-headed households has almost doubled since 1995/96, and women are spending more time engaged in agricultural work, while young people are shifting their time use towards education and income generating activities

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

FEARS AND CONCERNS STUDY/REPORT

FINDINGS

Baseline Survey SUAAHARA

These are the findings of economic events that may be associated as fear and concerns short-term illness 27.4 percent; loss of crop from weather 23.9 percent; loss of crop from other regions 18.2 percent; loss of livestock/poultry 18.2 percent; Loss of cattle 14.9% percent; accident/ injury 5.8 per cent; chronic long-term illness 3.1 percent.

BARRIERS AND GAPS STUDY/REPORT

FINDINGS One mother reported belief by some women that breastfeeding causes loss of beauty, particularly the shape of the breast

Helen Keller International (HKI) Action Against Malnutrition through Agriculture (AMMA) Project - Baitadi

Market Analysis of Complementary Food in Nepal – NCRSP 2012

Widely held view that breastfeeding should cease immediately upon becoming pregnant again, because of loss of nutrient value of the milk and likelihood of causing sickness A majority of respondents could think of no obvious benefits for the mother but had negative impact since she is giving blood to her child so that would make the mother weak

An underestimated constraint on child feeding is that the child’s food preparation takes a lot of mothers’ time, which is often already limited by other responsibilities

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS One widely held belief is that if a woman eats more during pregnancy she will have a bigger baby which can cause problems during labor

Literature Review of the Practices and Beliefs Regarding Maternal and Infant/ Child Nutrition in Nepal, Singh, J. Kathmandu, Academy for Educational Development, June 1998.

Social factors also influence the diet of pregnant women: women and girls usually eat after male members and children have eaten and have less access to food from animal sources and other special foods Recently delivered mothers considered impure and not allowed to eat with other family members until the purification ceremony - mothers’ food intake limited during this period in some communities Women in mid and far western hill regions practice a system in which the recently delivered women are kept in the cowshed outside their homes in very unhygienic conditions In some cultures, belief of a connection between stomach and womb is the basis for resting both by not giving food to the mothers. A range of issues impacting maternal under-nutrition has been identified to be addressed under the Health Sector Strategy 2013–2017

Health Sector Strategy for Addressing Maternal under Nutrition 2013 – 2017

• Early marriage —early pregnancy and child bearing • Large family size (less attention to adolescent girls) • Low priority and status of girls • Low school enrolment, attendance and drop-out of girls • Inequitable intra-household food distribution • Pregnancy is not considered a special condition for more attention and care • Low priority given to women compared to other family members with regard to their dietary and health needs • Inequitable intra-household food distribution • Frequent child bearing • Food taboos, beliefs and practices. There are taboos surrounding foods being hot or being cold. Foods like pumpkin and spinach are not eaten because they are cold foods. Also, women eat less when they are pregnant because they believe that the less you eat the smaller the baby and easier to deliver. Finally, women eat last and eat what is left over after everyone (husband, mothers-in-law, and children) has eaten.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS Pregnant reported that they visit health facility with mother-in-law, other relatives, husband, main barrier to getting ANC is shyness

Formative Research SUAAHARA 2012

Family planning is generally viewed as a women’s concern, men usually have little involvement Husband and family members opposed a women using of birth control if she had not yet produced a son Mother-in-law source of information regarding child feeding, child care and food during pregnancy.

ACCESS AND AVAILABILITY

STUDY/REPORT

FINDINGS

Primary Health Care Development: Where is Nepal after 30 years of Alma Ata Declaration – Karkee R, Jha M

Out of 75 districts, 60 have district health offices, 65 have district hospitals, and 15 have district public health offices. There are 209 PHCC (0.8 PHCC per 100000 population), 677 HPs, 3126 SHPs, 15257 TBAs and 48445 FCHVs. This has resulted in 12-fold growth in health facilities during 1992-1996. Sixty two percent of people have access to HP/SHP within half an hour of travel on foot

Annual Report of Department of Health Services 2012/13

This report is mainly based on information collected by DoHS’s Health Management Information System (HMIS) from health institutions across Nepal. A total of 95 public hospitals, 205 primary health care centers (PHCCs), 822 health posts (HPs) and 2,987 sub health posts (SHPs) reported to HMIS in 2012/13. Similarly 12,821 primary health care/outreach clinics (PHC/ORC), 16,646 Expanded Program of Immunization (EPI) clinics and 48,897 Female Community Health Volunteers (FCHVs). A total of 445 NGO and 476 private health institutions also reported to HMIS this year.

Formative Research SUAAHARA

Work load and distance to the place of their work hinder breastfeeding

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS

Baseline Survey SUAAHARA

Less than half of newborns received check-ups within two days of birth. When children suffered from diarrhea, families visited the pharmacy and subhealth post most frequently (41 percent and 28 percent respectively). Likewise, for fever/cough, 38 percent and 22 percent visited the pharmacy and sub-health post, respectively

Baseline Survey SUAAHARA

Mothers consult FCHVs, but the FCHVâ&#x20AC;&#x2122;s current strength appears to be in delivering interventions that are product driven, for example, vitamin A supplementation and deworming. Their role in postnatal and newborn care is not strong in nutrition and health behaviors the survey shows very poor knowledge and capacity of FCHVs in the realms of health and nutrition. Recommendation was that SUAAHARA and the government of Nepal needs to make heavy and rapid investment in strengthening the existing FCHV system as well as other systems of community mobilization and outreach through interpersonal communication to deliver high quality maternal and child health and nutrition services.

TRUST AND DISTRUST STUDY/REPORT

FINDINGS FCHVs stand out as the focal person relating to child health that parents contact within study districts. In the quantitative study, FCHVs were by far the chief source of information (over 90 percent of the cases) for both routine immunization as well as National Immunization Day (NID) campaign.

Formative Research on Strengthening Access and Utilization of Immunization Services in Eight Terai Districts of Nepal

FCHVs also surface as the most trusted (93 percent) source of interpersonal communication; they are one of the most important influential figures relating to child immunization in rural settings At community level, prominent individuals/leaders in most communities are mukhiyas and influentials in the Dalit community are called manyajans and they can help sway immunization participation. In most marginalized communities in the three districts investigated, there are group leaders, manyanjans who are respected figureheads in their respective communities and their words are universally accepted.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

ECONOMIC/WORK/AFFORDABILITY STUDY/REPORT

FINDINGS Breastfeeding not practiced exclusively for the first six months due to their low breast milk production resulting from inadequate dietary intake, sickness, excessive household chores and early return to work affecting mother’s health.

Helen Keller International (HKI) AMMA Project Ghee, meat, and milk are considered good for new mothers for breastBaitadi feeding –

Most lactating mothers, unable to afford special foods, consume the usual family diet Soap was seen as luxury and expensive item

Formative Research SUAAHARA

Heavy household chores made it difficult to pay attention to household hygiene

GENDER ISSUES STUDY/REPORT

Formative Research SUAAHARA

FINDINGS Fathers not being involved in taking care of the child because it is traditionally perceived as a women’s work so it is not fit in the society for male involvement Women have limited decision making power regarding infant feeding practices as it is often influenced or made by the mother-in-law or the father, which is a reflection of their low status

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS Seven percent of parents who want to marry their daughter before the age 18. The key reason for doing so were because their daughter would elope 48 percent; to escape early from their responsibility 46 percent; and following tradition 27 percent. Some of the qualitative insights for early marriages were increasing dowry culture in terai districts, poor economic conditions, fear their daughter will be sexually harassed.

UNFPA, HERD, Perception Survey 2013

During FGDs in different districts both parents were asked the reasons behind early age marriages, their responses were: desire of parents to see their grandchildren before they get old; parents had fear that their daughter will be sexually harassed and violated (some participants used word ‘rape’ to donate sexual violation); male domination, fathers primarily are decision-maker about when their daughters marry; the “misuse” of modern communication technologies by adolescents i.e. social electronic media, mobile phones where they get in touch with various people and easily diverted to immature love leading to elopement and early age marriages concerned raised mostly my mothers. Despite the fact that it is the early marriage that poses numerous threats, a married girl is perceived as safer from harm because it is believed that she has a husband to watch over her.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS Forty-three percent of men vs 12 percent women are empowered in the five domains of agriculture production (decision about agriculture production, access to and decision-making power over productive resources, control over use of income, leadership in community and time use) About 90 percent of women are involved in food crops production and raising livestock however less than 20 percent of women involved in wage and salary employments or non-farm activities. Among women involved in household productive activities the majority report to have at least some inputs into decision making for these activities.

Baseline Survey SUAAHARA The Nepal Thematic Report on Food Security and Nutrition (NTRFSN) 2013

Women have less control over decision-making regarding income than they do for decision-making more generally. In food crop farming, cash crop farming, livestock raising and fishing at least one in four report to have no input at all in decisions on income generated With respective to leadership, women participation in community group is quite low. In many instances, groups do not exists even if they exist 10 to 15 percent of women are members or active members Majority of the women report that they are not at all comfortable or have great difficulty speaking in public In 24 hours women resting time is on average 10 hours, eight hours work (agriculture and domestic work), six hours spent on personal care and other leisure activities. The detail break down of 24 hours spent by women are: sleeping/resting 10 hrs; agriculture labor 4.2 hrs; domestic labor 4.1; care for others 2.2 hrs; personal care (eating drinking, hygiene) 1.8 hrs; leisure including social and religious gathering 1.2 hrs; other labor 0.3 hrs; other 0.1 [The Nepal Thematic Report on Food Security and Nutrition (NTRFSN) 2013 reports]

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

REGION AND ETHNIC GROUP DIFFERENCES STUDY/REPORT

FINDINGS Food energy intake varied significantly between Nepal’s geographic regions per capita intake of calories highest in the rural terai - central (2,762 Kcal per day), compared to the lowest in the rural hills - mid and far western (2,331 Kcal per day) Areas with high levels of both inadequate FCS and food poverty include the mountains, rural hills - central, eastern and mid- western, and rural terai – mid western Important disparity between stunting and wasting, also evident when considering only the ecological zone - prevalence of stunting is highest among the Dalits in the hills and terai, but somewhat lower among the Janjati in the terai region; prevalence of wasting notably higher among the Janjati than in any of the other groups; among Newars, prevalence of both stunting and wasting lowest A significantly higher prevalence of under-nutrition is found in rural areas compared to urban areas

Nepal Thematic Report on Food Security and Nutrition 2013

Populations living in the mountains and mid- and far-western hills have poorer food consumption and a higher prevalence of under-nutrition, particularly for stunting. For the poorest households, the food insecurity is highest. Under-nutrition also improves with income, but it is noted that that it is still prevalent even among the wealthiest households, suggesting that other factors beyond food availability and income are influencing nutrition. The role of cultural practices and social exclusion and their influence on utilization and consumption need to be examined in more detail at all levels Caste, ethnicity and religion are key determinants of food and nutrition security Marked differences in nutrition exist across ethnic and caste groups. Dalits living in the terai and hill areas have the worst food consumption score, whereas Brahmins living in the same areas have the best. In addition, the average food security indicator scores for Dalits and Janjatis are generally worse than the average indicator scores for any one geographical region. This highlights the importance of providing assistance to marginalized households living in relatively better off areas, in addition to geographically based programs of support, to achieve national food and nutrition security

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Poor educational attainment by the household head and mothers linked to poor food and nutrition security outcomes in the findings. Literate heads of households tend to consume a better quality diet than illiterate heads of households. Mothers with little or no education were more than twice as likely to have children suffering from stunting compared to children with mothers having 12 or more years of education. Sustaining and improving education is a priority intervention to ensure overall food and nutrition security countrywide

Formative Research on Strengthening Access and Utilization of Immunization Services in Eight Terai Districts of Nepal

Baseline Survey SUAAHARA

Among different ethnic background the Dom and the Muslim population appear to lag behind in child immunization. Misconception found in the Muslim community is that injecting an infant/child will in the future makes him/her infertile. Doms are social outcasts and no one belonging to other castes/ethnic groups visits them. Their participation in routine immunization as well as in NID is not seen favorably by other groups which dampens the immunization efforts run by health institutions. This group usually lives in secluded place away from villages and their habitation is sparsely populated, which adds geographical barrier to the existing social one.

Child stunting prevalence is the highest in the mountain areas while wasting and anemia is most prevalent in the terai

KEY INFLUENCERS

STUDY/REPORT

FINDINGS

Formative Research on Strengthening Access and Utilization of Immunization Services in Eight Terai Districts of Nepal

As outlined in the trust and distrust section FCHVs area key influencer. The other influencers in terai are community leaders like mukhiyas, and manyanjans (named use by Dalit community).

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

STUDY/REPORT

FINDINGS

Nepal Demographic and Health Survey (DHS) 2011

Common information and communication devices possessed by households are 75 percent households have mobile phones; 50 percent households have a radio; and a similar proportion (47 percent) has a television and eight percent households have computer (NDHS 2011).

Formative Research SUAAHARA 2012

FCHV and traditional healers play important roles as sources of health information because they are well known in community and often, according to many respondents, are more convenient to access than health centers. Many respondents said they received advice regarding the health of their children. FCHV and traditional healers describe counseling parents on a wide-variety of topics including nutrition, care during illness and hygiene and sanitation. FCHV played a particularly important role in conveying information to pregnant women about accessing prenatal care and about vitamin supplements as well as taking children for immunization. Traditional healers were generally consulted in the case of illness, particularly if the illness was thought to have an underlying spiritual cause.

Multivariate Analysis of Main Determinants of Non-optimal Complementary Feeding, using 2006 DHS data (Joshi, N. et al. 2012)

Baseline Survey SUAAHARA

The infants of mothers listening to radio almost every day and infants of mothers having had four or more antenatal visits had significantly higher dietary diversity compared to the infants whose mothers had limited exposure to media and had less or no antenatal clinic visits. Compared with mothers with higher level of education, those having primary level of education or illiterate reportedly risked poor dietary diversity. The risk for inadequate dietary diversity gradually increasing with lowering wealth index quintiles.

Mothers most preferred source of information on health and nutrition are radio/FM 63.4 percent, FCHV 41.1 percent, health facility 39.4 percent, TV 36.6 percent, community and village gathering 8.9 percent, and mothers group 5.8 percent.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

POINT OF SEEKING HEALTH SERVICES STUDY/REPORT

FINDINGS

Formative Research on Strengthening Access and Utilization of Immunization Services in Eight Terai Districts in Nepal

As out lined in the trust and distrust section FCHVs is one of the key influencer. The other influencers in terai are community leaders like mukhiyas and manyajans (in case of Dalit community).

First step of treatment was done at home. In case if the health condition of the child did not improve and there was consistent increased episode of diarrhea for more than two days and dangerous sign (blood in stool, watery stool, skin wrinkles and weakness) were observed then the child underwent second step of treatment.

Formative Research on Zinc and Oral Rehydration Salts (ORS) Supplementation in the Treatment of Diarrhea

Second step generally mothers and caretakers visited health post and pharmacists and some visited FCHV for treatment of childhood diarrhea. It was observed that different geographic regions responded to diarrhea cases in different ways: in terai region children were taken to pharmacist, in hill districts children were taken to health facility, and in Kailali District diarrhea cases were taken to FCHV. It is to be noted that more than a half of the respondents visited traditional healers as well as undergo allopathic treatment at the same time. Their tradition belief is that in visiting traditional healer will avoid an evil spell being placed on their child In the third step if after following first and second ORS treatment the child did not improve then child was taken to private or government hospitals for further care and treatment.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

ACCESS TO CLEAN WATER STUDY/REPORT

FINDINGS Ninety-one percent of the households do not treat their drinking water.

Baseline Study of Public Private Partnership for Hand Wash project in Nepal

The main source of drinking water are public tap/stand pipe 32.1 percent, Tubewell/hand pump/rower pump 31.9 percent, and piped to yard/plot 15.0 percent, Other sources of drinking water include: unprotected spring 8.9 percent, piped into dwelling 4.3 percent, protected spring 3.0 percent, piped to neighbor 2.9 percent, surface water 1.5 percent, protected dug well 0.2 percent, unprotected dug well 0.2 percent, rainwater 0.1 percent

Child and Maternal Nutrition Status and Ethnicity The World Bank activity also focuses on ethnic populations in Nepal and how or if their behavioral practices related to breastfeeding and Infant and Young Child Feeding are different than the majority populations. The amount of research specific to breastfeeding and IYCF among ethnic groups is generally quantitative research (as demonstrated in the following reviews) by specific practices. The research does not show the reasons why these practices and behaviors are done. There was almost no quality qualitative research on the “why” of breastfeeding and IYCF practices and behaviors. The research that has been conducted was reviewed and found to be either incomplete or less rigorous than acceptable. The data from the qualitative could be used as anecdotal or informational but not a basis for decisionmaking. Several of the reports reference “Other” minority groups that may include Chepang, Jogi, Sanyasi, Rautay and Rajhi. The minority population is specific to the districts and the Village Development Committee (VDC) where the research was conducted. The research for this activity will need to determine the whys that affect their decisions related to breastfeeding and complementary feeding. Areas of focus may include the level of education of mothers; access to breastfeeding instructions at birth or access to complementary food products; as well as the cultural belief and practices (social norms). Following are key findings from the research on child and maternal nutrition status upon ethnic populations in Nepal. The interviewer reviewed the data and reports as well as talked with experts in ethnic populations. Call sheet is included in the Annex of the Assessment Report by Another Option for the World Bank. GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

Nepal Household Survey â&#x20AC;&#x201C; 2012 Nepal Health Sector Program II Dr. Suresh Mehata, Dr. Sushil Chandra Baral, Dr. Padam Bahadur Chand, Dr. Dipendra Raman Singh, Mr. Pradeep Poudel, Dr. Sarah Barnett Early breastfeeding Nearly half the mothers (49 percent) initiated breastfeeding within an hour of delivery (Table 1). This is similar to the NDHS 2011 finding. There were significant differences in early initiation of breastfeeding by ecological zone: mothers from mountain districts (59 percent) were more likely to initiate early breastfeeding than those in terai districts (40 percent). Significant differences were also observed between caste/ethnic groups, with only 27 percent of those in the Terai/Madhesi group initiating breastfeeding within one hour, compared to 58 percent in the Janjati group. There were no significant differences in early initiation of breastfeeding by urban/rural residence or wealth quintile. The largest variation was seen between castes and ethnicities: only 27 percent of those in the Terai/Madhesi group and 36 percent of the Muslim group had initiated breastfeeding within one hour, compared to 58 percent in the Janjati group. Exclusive breastfeeding Two-thirds of infants (aged six to 12 months) were exclusively breastfed (66 percent) for the first five months. This is similar to the NDHS 2011 finding at 70 percent. There were significant differences in exclusive breastfeeding by ecological zone and caste/ethnic group. Four-fifths of infants from the Terai (80 percent) were exclusively breastfed, compared to less than half from mountain districts (47 percent). Significant differences in exclusive breastfeeding between caste and ethnic groups were also observed, with Muslims (92 percent) more likely to breastfeed exclusively than Brahmins/Chhetris (55 percent). As with early initiation of breastfeeding, there were no significant differences in exclusive breastfeeding by urban/rural residence or wealth quintile.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

Table 1: Newborn Care Practices

Category

Percentage six to 35 months children consuming Vitamin A-rich food last 24 hours

Percentage six to 35 months children consuming iron-rich food last 24 hours

Percentage six to 59 months children given Vitamin A supplements last six months

Male

62.9

22.2

92.4

Female

71.1

27.0

91.7

Hill Brahmin

70.5

12.5

96.1

Hill Chhetri

69.5

21.5

92.9

Other Terai/ Madhesi Castes

55.0

16.0

91.6

Hill Dalit

72.6

30.6

88.6

Terai/Madhesi/ Dalit

67.6

19.2

91.0

Hill Janjati

74.7

43,9

90.4

Terai Janjati

63.4

22.4

95,8

Muslim

61.9

19.2

91.2

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

Socio-demographic Features of Mothers in Relation to Duration of Breastfeeding in Manipal Teaching Hospital, Pokhara, Nepal Basnet S, Gauchan E, Malla K, MallaT,Koirala DP, Rao KS, Sedai Y, Saha R Department of Pediatrics, Manipal Teaching Hospital, Pokhara, Nepal 2012 Most children are likely to be breastfed on the first day of birth (87 percent). There should be some focus on the remaining 13 percent not breastfed on the first day. In this regard, special attention should be placed on the significant proportion of Madhesi (38 percent), Dalit (36 percent) and Muslim (28 percent) children not breastfed on the first day of their birth. This delay could be harmful to the newborn. Table 2 reveals that these children most often receive pre-lacteal feed and not breast milk. Table 4: Duration of Breastfeeding and Ethnicity

Ethnicity

Duration of Breast Feeding (months)

Chhetri

Newar -

Gurung

Magar

Tamang

Kiranti

Sherpa

Thakali

Dalit

Muslim

Others

Table 4 highlights the duration of breastfeeding across ethnicity/caste. It ranges from 30 months for Kirantis, Thakalis and Muslims to 53 months for Sherpas; with most ethnic groups breastfeeding between 41-45 months.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

2012 UNICEF Report: Analysis of trends in nutrition of children and women in Nepal Jennifer Crum MPH, John Mason PhD, Paul Hutchinson, PhD; Tulane University, School of Public Health and Tropical Medicine The UNICEF Report advised caution in interpreting the associations between caste/ethnicity and child nutrition outcomes. However, the data analyzed showed that Dalits had the highest stunting prevalence and the Madhesi the highest prevalence of wasting through time. Prevalence of both stunting (over 50 percent) and underweight (approximately 50 percent) is highest among Dalits, Muslims and Others indicating that child under-nutrition is a substantial problem. Analysis of wasting shows that the Madhesi group has the highest prevalence at 23 percent, which is deemed near emergency levels. The Newar group has the lowest prevalence of child under-nutrition for all three measures, followed by Janjati and Brahman/Chhetri. This analysis demonstrates the need to target nutrition interventions to caste/ethnic groups with the largest burden of poor child nutritional status. Targeting nutrition interventions by location and caste/ethnic group is indicated. Table 1: Newborn Care Practices

Ethnicity

Diet Diversity

Minimum meal frequency

Minimum acceptable diet

Early initiation of breast feeding

Brahmin

48.8

81.4

42.4

52.4

Madhesi

4.5

63.8

4.5

30.6

Dalit

20.1

83.4

18.9

41.7

Newar

35.2

94.1

29.3

47.3

Janjati

27.6

82.1

25.9

46.8

Muslim

11.5

69.8

6.5

35.8

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

Targeting by ethnic group/caste should be prioritized for the Madhesi group, which exhibited the poorest IYCF practices considered here, followed by the Muslim and Dalit. Prevalence of both stunting and underweight is highest in the same three groups over the period; Dalit, Other and Muslim. Castes/ethnic groups classified as ‘Other’ have consistently the highest estimates of stunting and underweight, though ranking changes between the two measures for the Muslim and Dalit groups. The difference between these latter two groups is 6ppts for stunting and 1ppt for underweight. Importantly, all of the above mentioned three caste/ethnic groups have a prevalence of greater than 50 percent for stunting and approximately 50 percent for underweight, indicating that child under-nutrition is a substantial problem among all. Analysis of wasting shows that the Madhesi group has the highest prevalence at 23 percent, which is near emergency levels, followed by those groups with highest prevalence estimates of stunting and underweight. The Newar group has the lowest prevalence of child undernutrition for all three measures, followed by Janajati and Brahman/Chhetri. This analysis demonstrates the need to target nutrition interventions to caste/ethnic groups with the largest burden of poor child nutritional status.

Gender, Caste and Ethnic Exclusion in Nepal: Following the Policy Process from Analysis to Action Lynn Bennett, TheWorld Bank Many poor Dalit and disadvantaged Janjati women have little time to spare for group activities that have benefited other women. Even when they are able to join various women’s groups, their voices are often muted by the more confident and highly-educated women unless special efforts are made to ensure that they participate in the governance of the group. Critical sites of disempowerment and social exclusion may vary for different categories of excluded people. For example, for women, the home and family is a key site where norms, beliefs and behaviors have to be changed to enable them to exercise their agency. Community norms and formal laws must also be changed, but change in the domestic site is fundamental. In contrast, for Dalits, the local community is where caste-based discrimination is likely to be most strongly enforced and harshly experienced. A senior Dalit man is still dominant within his family despite the restrictions he faces in the community. However, a Dalit woman who is subordinate in both the gender and the caste domains encounters discrimination in the home as well as in the community. Community-level discrimination against the Janjatis is much more muted and has in most cases been effectively countered by the pride Janjatis take in their ethnic identity and in the cultural traditions of their own group. For Janjatis, the most problematic site in terms of empowerment and inclusion is at the level of the state - in terms of laws, policies, resource allocation and representation.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

A Review of Policy, Strategy, Program Interventions and Evidences for Reducing Health and Nutrition Inequities (Draft) Save the Children. January 1, 2014 The highest disparity observed was in maternal and child under-nutrition among ethnic groups. The draft report revealed these differences: between Newars and Muslims in proportion of undernourished or thin (BMI<18 kg/m2) were 28 percent and between Newars and Dalits, 18 percent. The proportion of undernourished or thin among the Muslin women (36.6 percent) was over three times higher than Newars (eight percent). The proportion of underweight children among Muslims (31.7 percent) was over two times that of Newars (14.3 percent). The prevalence of maternal anemia among Muslims (54 percent) was over three times higher than Newars (17.2 percent). The analysis clearly pointed to a marked disparity in nutritional status between ethnic groups. The regression analysis showed that Dalit children, children from Terai/Madhesi have much higher odds of being underweight (OR 1.93) than Brahman/Chhetri, Newar, and Janjati children (Pandey et al, 2013). The practice of breastfeeding within one hour was higher among Newars (53.8 percent) than Muslims (33.8 percent). The gender difference in the coverage of child health services was less than three percentage points. (Pandey et al, 2013) There is significant disparity in the use of maternal health services across the ethnicity/caste divide. The proportion of Newars (68 percent) accessing institutional childbirth care was more than twice Muslims (32 percent) and almost three times more than Dalits (26 percent). The coverage of first antenatal care among the Newars (82.7 percent) was more than twice that of Muslims (34.7 percent). The current use of family planning methods of Muslims (25 percent) is less than half that of Newars (63.4 percent); yet, there is no separate targeted program to address this ethnic/caste disparity. An equity and access program was introduced in 2006 to improve equity in access to and utilization of maternal and newborn care. However, the disparity is still alarming. Although additional efforts were made to mainstream those groups through micro-planning the inequity has persisted. For example; disparity in the coverage of institutional childbirth care between Newars and Dalits increased from 39 percent to 42 percent. This demands that either the equity and access program should be revitalized or a separate program targeting Dalits and Muslims should be formulated to ensure their improved access to and use of available maternal health services.

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD â&#x20AC;&#x201C; AND NUTRITION-SECURITY IN NEPAL

A N N E X

DI S CU S S I O N S GU ID ES (S E V E N E N G L I SH -VER S ION S)

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: Mothers I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary feeding. II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We need your ideas so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose I will also take some notes to help us in this task. IV. Introduction and Warm Up Before we begin the discussions, I would like to get to know you a little better since I do not know much about you so, tell me a little about yourself. Tell me a little about your village, community, culture family/ interests. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Type of study participant

DG Mother’s Guide –

Demographics Please note down the following information: Age(approximate age will suffice if exact date not known) Education (non-literate, primary school, high school, college, post-graduate, technical training) Caste/Ethnicity Age at marriage Age at birth of first child Number, age and gender of children Household occupation Aspirations, Fears and Motivation Here the intention is to find out about the aspirations, dreams, fears and motivations of mothers 1. How do you spend your day, what are the activities you do, which one is your favorite activity and why? 2. What are the most important things in your life? What do you value very much? Why so? Can we rank here? 3. Can you tell me about your dreams and aspirations? 4. What changes would you have made to your life if you had complete control? 5. What are the things that make you worry? [Probe: health? Children? Security? Child’s education? Job/work? Money/income] Healthcare focus Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s talk more about that 6. What specific health concern do you worry about? [Probe: priorities of health] 7. You said that health is something that concerns you. Who do you often talk to get information about health issues? (Probe: Mother/Mother in law/Friends/Neighbors) 8. Do you have other valuable sources of information on health? [technology, radio, TV, mobile phones - texting] 9. Who do you believe/feel are the most reliable sources for good information on healthcare issues? Who do you trust most? [probe: Anyone else? is that who you trust]

DG Mother’s Guide –

10. Is there anything you personally can do to solve these health concerns you mentioned? [Probe: 11. If yes, what have you done? •

Do you know what motivated you to do that? EXPLORE MORE DETAILS TO UNDERSTAND STRONG MOTIVATOR

12. Is there anything that you have wanted to do but felt that you couldn’t? Have you faced any obstacles that have prevented you from taking any action? What are they? How did you feel about that? Do you think that you should overcome these barriers in the future? How would you overcome?

Interviewer: Let’s now talk about when you first learned you were pregnant. Pregnancy 13. Can you remember the advice you received from health worker (HW, FCHV, TH) regarding what to do when pregnant? [Probe: eating, sleeping, working, breastfeeding] 14. Can you remember any advice you received from family and friends (Mother in law, husband, community leader, religious leader)? [Probe: eating, sleeping, working, breastfeeding]? 15. Were there other sources of information you received when you were pregnant? [technology, mass media, workplace] 16. Whom do you trust the most for advice? Whose advice do you usually follow? 17. In your community what type of support did you receive when you were pregnant and shortly after you had the baby? (Why? who, what do they do and how do they support?) How are they helpful? Breast Feeding Divide question – first child and multiple births 18. Is this your first child? [If so continue through 18b-21; if multiple births ask 18a.] 18a. Did you exclusively breastfeed your other children? If so, for how long?

DG Mother’s Guide –

18b.First child: Do you plan on exclusively breastfeeding your child? (or are you now exclusively breastfeeding your child)? 19. Earlier you said the HCW talked about breastfeeding? Do you remember what she told you? [Probe: 1 hour, exclusive, no food, no water, how often] 20. How do you feel about breastfeeding? [Probe: negatives and positives; what did breastfeeding mean to you whenever you heard it discussed] 21. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe: What are they? Is there something that could be done to make it easier to breastfeed] Complementary feeding 22. When you talked to your health care worker/mother-in-law (see response above) did they discuss with you feeding your child healthy foods or complementary/instant feeding? When you should begin complementary feeding? 23. Were you familiar with instant feeding? Tell me what you know about it: [Probe: when to start; how to use it; benefits] 24. Who has been the most influential in choosing what foods to feed your child? 25. Whose opinion do you value the most in regard to your child’s health? 26. Do you feel you have the power to make your own decisions? [Probe. About your health, your child’s, how to care for him/her] 27. What other beliefs influence your decisions about certain foods – diversity of foods? 28. Ask women what foods they think are good for their babies and what foods they think are bad for their babies–just make two lists. If there is time you could even rank them from healthiest to unhealthiest. 29. Who in the family would make the decision to use instant complementary foods? [Probe: husband, mother, her, HCW – is it discussed?] 30. Who would buy the instant complementary food? Husband/Mothers (you)/other caregivers? 31. Have you seen micronutrient powders or instant foods in the market? Has the HCW or your family talked about them? 32. Besides you, who looks after your children?

DG Mother’s Guide –

Challenges and Barriers 33. What prevailing feeding practices put the lives of infants and young children at risk? [Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding, amount of food, texture of food, variety, active feeding—including food handling? 34. Do you believe you have proper access to health services regarding breastfeeding instruction and complementary feeding? 35. Do you feel you understand the importance of breastfeeding on your child’s health and well-being? Is there anything else you want to tell me? Thank you for your cooperation

DG Mother’s Guide –

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: mothers-in-law I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary foods. II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We need your ideas so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose I will also take some notes to help us in this task. IV. Introduction and Warm Up Before we begin the discussions, I would like to get to know you a little better since I do not know much about you so, tell me a little about yourself. Tell me a little about your village, community, culture family/ interests. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Type of study participant

Mothers-‐in-‐law Discussion Guide

Demographics Please note down the following information: Age(approximate age will suffice if exact date not known) Education (non-literate, primary school, high school, college, post-graduate, technical training) Caste/Ethnicity Age at marriage Age at birth of first child Number, age and gender of children Household occupation Aspirations, Fears and Motivation Here the intention is to find out about the aspirations, dreams, fears and motivations of fathers 1. How do you spend your day, what are the activities you do, which one is your favorite activity and why? 2. What are the most important things in your life? What do you value very much? Why so? Can we rank here? 3. Can you tell me about your dreams and aspirations? 4. What changes would you have made to your life if you had complete control? 5. What are the things that make you worry? [Probe: health? Children? Grandchildren? Security? Education? Job/work? Money/income] 6. You mentioned how important your children and grandchildren and their well-being are to you. What do you want for your children? For your grandchildren? What are your dreams and aspirations for them? What challenges or obstacles stand in the way to achieve/realize these aspirations? Healthcare focus Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s talk more about that 7. What specific health concern do you worry about? [Probe: priorities of health]

Mothers-‐in-‐law Discussion Guide

8. Earlier you said that health is something that concerns you. Who do you often talk to get information about health issues? (Probe: Daughter-in-law, Son, Friends) 9. Do you have other valuable sources where you receive information on health? [technology, radio, TV, internet, mobile phones - texting] 10. Who do you believe/feel are the most reliable sources for good information on healthcare issues? [probe: Anyone else? is that who you trust?] 11. Is there anything you personally can do to solve these health concerns you mentioned? [Probe: 12. Have you done that? [Probe: •

Do you know what motivated you to do that? EXPLORE MORE DETAILS TO UNDERSTAND STRONG MOTIVATOR

Interviewer: Let’s now talk about when your daughter-in-law found out that she was pregnant. Pregnancy 14. Did you go with her to the clinic? If so, can you remember the advice she received from health worker (HW, FCHV, TH) in regards to what to do when pregnant? [Probe: eating, sleeping, working, breastfeeding] 15. Can you remember any advice you or she received from others such as family and friends (relatives, friends, community leader, religious leader)? [Probe: eating, sleeping, working, breastfeeding]? 16. Were there other sources of information where you or she received when you were pregnant? [technology, mass media, workplace] 17. Whom do you trust the most for advice? Whose advice do you usually follow? Whose advice is your daughter-in-law most likely to follow? (If respondent says mine/my advice: other than your advice whose advice is she most likely to follow?) Mothers-‐in-‐law Discussion Guide

18. In your community what type of support did you or your daughter-in-law receive when she was pregnant and shortly after the baby was born? (Why? who, what do they do and how do they support?) How are they helpful? Breast Feeding 19. Is this her first child? 20. Did you exclusively breastfeed your children? Do you remember for how long – months or days? 21. Have you talked to your daughter-in-law about her pregnancy? 21. Can you tell me what advice you have told her? [Probe: breastfeeding? Working? Exercise? Eating? if breastfeeding, Probe for specifics - when do you start? For how long? Understanding of exclusive] 22. Do you have an opinion about breastfeeding? [Probe: positive benefits; negative] 23. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe: What are they? Is there something that could be done to make it easier to breastfeed] 24. When people talk about breastfeeding how would you define it? [Probe: exclusively (explain that term), breastfeeding with regular food] Complementary feeding 25. Did you use instant/complementary feeding for your children? Tell me about your experience [Probe: when did you start, what kind of foods, did you prepare it or buy it, how long did you use it] 26. Who has been the most influential in choosing what foods to feed your grandchild? 27. What role do you have in feeding your grandchild? What role does your son have? 28. Do you feel that you have the power to make your own decisions [Probe. About your health, your children, how to care for him or her] 29. Do you feel that your daughter-in-law has the power to make her own decisions? (Same probe as above) 30. What other beliefs influence your decisions about certain foods – diversity of foods?

Mothers-‐in-‐law Discussion Guide

31. What foods do you think are good for your baby and what foods do you think are bad for your baby –just make two (2) lists. If there is time you could even rank them from healthiest to unhealthiest. [this is to determine if there are food selection by ethnic groups as well as general practices] a. Do you ever feed the baby instant complementary foods? 32. Who in the family would make the decision to use instant complementary foods? [Probe: husband, mother, her, HCW – is it discussed?] 33. Who would buy the instant complementary food? Husband/Mothers/you/other caregivers? 34. Have you seen micronutrient powders or instant foods in the market? Has the HCW or your family talked about them? 35. Besides your wife, who looks after your children? b. How often do you personally look after the children? c. When is that specifically? Challenges and Barriers 36. What prevailing feeding practices put the lives of infants and young children at risk? [Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding, amount of food, texture of food, variety, active feeding—including food handling? 37. Do you believe you have proper access to health services regarding breastfeeding instruction and complementary feeding? 38. Do you feel you understand the value of breastfeeding on your child’s health and well-being? Is there anything else you want to tell me? Thank you for your kind cooperation

Mothers-‐in-‐law Discussion Guide

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: Fathers I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary foods. II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We need your ideas so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose I will also take some notes to help us in this task. IV. Introduction and Warm Up Before we begin the discussions, I would like to get to know you a little better since I do not know much about you so, tell me a little about yourself. Tell me a little about your village, community, culture family/ interests. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Type of study participant

Father’s Guide

Demographics Please note down the following information: Age(approximate age will suffice if exact date not known) Education (non-literate, primary school, high school, college, post-graduate, technical training) Caste/Ethnicity Age at marriage Age at birth of first child Number, age and gender of children Household occupation Aspirations, Fears and Motivation Here the intention is to find out about the aspirations, dreams, fears and motivations of fathers 1. How do you spend your day, what are the activities you do, which one is your favorite activity and why? 2. What are the most important things in your life? What do you value very much? Why so? Can we rank here? 3. Can you tell me about your dreams and aspirations? 4. What changes would you have made to your life if you had complete control? 5. What are the things that make you worry? [Probe: health? Children? Security? Child’s education? Job/work? Money/income] 6. You mentioned how important your children and their well-being are to you. What do you want for your children? What are your dreams and aspirations for them? What challenges or obstacles stand in the way to achieve/realize these aspirations? Healthcare focus Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s talk more about that 7. What specific health concern do you worry about? [Probe: priorities of health] 8. Earlier you said that health is something that concerns you. Who do you often talk to get information about health issues? (Probe: Mother/Mother in law/Friends) Father’s Guide

9. Do you have other valuable sources where you receive information on health? [technology, radio, TV, internet, mobile phones - texting] 10. Who do you believe/feel are the most reliable sources for good information on healthcare issues? Who do you trust most? [Probe: Anyone else? is that who you trust] 11. Is there anything you personally can do to solve these health concerns you mentioned? [Probe] 12. Have you done that? [Probe: How] •

Do you know what motivated you to do that? EXPLORE MORE DETAILS TO UNDERSTAND STRONG MOTIVATOR

13. Is there anything that you have wanted to do but felt that you couldn’t? Have you faced any obstacles that have prevented you from taking any action? What are they? How did you feel about that? Do you think that you should overcome these barriers in the future? How would you overcome? Interviewer: Let’s now talk about when your wife found out that she was pregnant. Pregnancy 14. Did you go with her to the clinic? If so, can you remember the advice you or she received from health worker (HW, FCHV, TH) in regards to what to do when pregnant? [Probe: eating, sleeping, working, breastfeeding] 15. Can you remember any advice you or she received from family and friends (Mother in law, community leader, religious leader)? [Probe: eating, sleeping, working, breastfeeding]? 16. Were there other sources of information where you or she received when you were pregnant? [technology, mass media, workplace] 17. Whom do you trust the most for advice? Whose advice do you usually follow? Whose advice is your wife most likely to follow? (If respondent says mine/my advice: other than your advice whose advice is she most likely to follow?) 18. In your community what type of support did you or your wife receives when she was pregnant and shortly after the baby was born? (Why? who, what do they do and how do they support?) How are they helpful? Breast Feeding Divide question – first child and multiple births Father’s Guide

19. Is this your first child? [If so continue through 20b-23; if multiple births ask 20a.] 20a.Did your wife exclusively breastfeed your other children? Do you remember for how long – months or days? 20b.If this is your first child, who have you talked to about your wife’s pregnancy? [Probe: HCW, mothers-in-law, friend] 21. Can you tell me what you remember they told you? [Probe: breastfeeding? Working? Exercise? Eating? if breastfeeding, when do you start? For how long? Understanding of exclusive] 22. Do you have an opinion about breastfeeding? [Probe: positives, negatives] 23. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe: What are they? Is there something that could be done to make it easier to breastfeed] Complementary feeding 24.Whenyou/your wife talked to your health care worker/mother-in-law (see response above) did they discuss with you feeding your child healthy foods or complementary/instant feeding? 25. Were you familiar with instant complementary feeding? Tell me what you know about it: [Probe: when to start; what foods to start with; for how long; water] 26. Who has been the most influential in choosing what foods to feed your child? 27. What role do you have in feeding your child? What role does your wife have? Do you feel you have the power to make your own decisions? [Probe. About your health, your child’s, how to care for him/her] 28. Do you feel that your wife has the power to make her own decisions? (Same probe as above) 29. What other beliefs influence your decisions about certain foods – diversity of foods? 30. What foods do you think are good for your baby and what foods do you think are bad for your baby–just make 2 lists. If there is time you could even rank them from healthiest to unhealthiest. Father’s Guide

a. Do you ever feed the baby instant complementary foods? 31. Who in the family would make the decision to use instant complementary foods? [Probe: husband, mother, her, HCW – is it discussed?] 32. Who would buy the instant complementary food? Husband/Mothers(you)/other caregivers? 33. Have you seen micronutrient powders or instant foods in the market? Has the HCW or your family talked about them? 34. Besides your wife, who looks after your children? b. How often do you personally look after the children? c. When is that specifically? Challenges and Barriers 35. What prevailing feeding practices put the lives of infants and young children at risk? [Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding, amount of food, texture of food, variety, active feeding—including food handling] 36. Do you believe you have proper access to health services regarding breastfeeding instruction and complementary feeding? 37. Do you feel you understand the value of breastfeeding on your child’s health and well-being? Is there anything else you want to tell me? Thank you for your kind cooperation.

Father’s Guide

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: HW/FCHV/Traditional Healer I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to study on Gender Equality and Social Inclusion related to breastfeeding and complementary feeding. II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said today is confidential and will only be used for this research purpose. I will also take some notes to help us in this task. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Type of study participant  Name of Respondent  Date of interview Respondent Background Please note down the following information: Sex Age HCW DG

Caste/Ethnic group Education Years in Service Position Duration at the health facility Mobile phone number Pregnancy 1. Can you share with me about the kind of work you are involved in related to breast feeding and infant and young child feeding? What problems do you face in your work? How do you overcome them? 2. Do you get training or support for your work? From what organization? How helpful has the training been? Probe: any training specific to breast feeding or IYCF? 3. [Role Play] What would you tell me if I were coming to the clinic and am pregnant for the first time: [Look for breastfeeding instructions and if mentioned specific instructions – 1 hour, exclusive, no water, no other foods] 4. You did (or didn’t) mentioned breastfeeding. When do you go into more detail with a pregnant women and her family about breastfeeding and instant foods? 5. What would you tell a woman who has already had a child? [Role Play again for woman with multiple births] 6. When women talk about breastfeeding what do you think they mean by breastfeeding? [Probe: is it only exclusive breastfeeding or intermittent with other foods or only for a few days] 7. What do you hear from women are the positives related to breastfeeding [Probe: healthy child, grows big, cultural norm]: what are the negatives of breastfeeding that you hear from mothers (and family members) [Probe: timely, hard to do, too many other demands, makes me unattractive] 8. Do you believe that pregnant women practice good nutrition behavior in your community? 9. If yes, how is it different from other women (that is, women who are not pregnant)? Resting, food, check ups, etc 10. If no, what are the constraints? [Probe] Breastfeeding 11. What would help mother’s better practice exclusive breastfeeding? What barriers do they face? How do they overcome them? [Probe] 12. What are the existing breastfeeding practices in your community? 13. What about child being breastfed within an hour of birth? What about Colostrum? 14. If not – what are the constraints 15. What about exclusive breast feeding to children till 6 months? 16. If not – why do you think so? Probe: social, cultural barriers 17. Why do you think breastfeeding is so important? [Probe] HCW DG

Complementary food 18. Can you elaborate a little on what kind of counseling you give to mothers about feeding complementary food for children? When do you start discussing complementary foods? 19. Can you tell me about the practices in the community regarding complementary food for children? What age do they typically start on instant feeding? What is the most common complementary food for children? How is it prepared? 20. What motivated mothers to practice healthy IYCF behaviors? 21. If no, what are the constraints for these mothers to practice healthy IYCF behaviors? 22. Do you have access to micronutrient powders in the clinic? If so, do you distribute them to mothers at the appropriate time? If not, do you recommend them to an NGO or vendor? Health Seeking Behaviors 23. What are most common health problems you see in children in your community? (Rank the health problem in order of prevalence in the community) 24. What is the perception of the community on child’s good health? Is it a priority? 25. If not the priority – why do you think so? Any constraints? What would motivate them? 26. How do you handle misattribution of nutrition related problems among children to being stricken by external forces (sato gayeko) or being complainer (runche)? 27. What is the counselling you provide to mothers with infants or children that are not eating? 28. What do you think prevents women from accessing health and nutrition services? 29. Do you feel that women (mothers) have the power to make their own decisions? [Probe. About health, about their children, about how to care for their children, about food selection for their children]. If so, how do they see it? If not, how do they see it.

Is there anything else you would like to add?

Thank you for kind cooperation

HCW DG

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL Question Guide: Influentials: Community and Business Leaders, Educators, Stakeholders I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to study on gender equality and social inclusion for health and nutrition specifically breastfeeding and complementary foods. II. Ground Rules We are interested in your opinions and feelings. There is no right or wrong answers. We need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study.

III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose I will also take some notes to help us in this task. Attention to moderator: please self speak in audio the following:

 District  VDC  Ward  Name of Participant  Date of interview Demographic Please note down the following information:

Sex Age Caste/Ethnic group Education Name of organization/society Position DG Community leaders & stakeholders

Duration with the organization Mobile phone number Fears and Concerns 1. What are the key concerns that you have about your community? (Things could be Livelihood, food security, Health, corruption, law and order, child education, gender/caste ethnic group discrimination) 2. Could you prioritize them – 1 thru 5? 3. Why and how do they affect you and your community? Probe reason and source for each concern. 4. What can be done to overcome these concerns? What barriers prevent overcoming them? You did (or didn’t) mentioned gender-issues or social inclusion for all populations. 5. Do you see gender as having an effect on these community issues – either directly or indirectly? 6. Are there gender-related restraints that limit a woman’s health and the health of her child? Including health services and decisions-related to adequately caring for her child? [Probe: traditional beliefs, cultural or social norms, dynamics in the household, dynamics in the community] 7. What would you recommend as ways to reduce these barriers? 8. Who are the main people that influence or give advice to women? Who are the main people that influence or give advice to women during pregnancy and breastfeeding? (Mother in law, husband, FCHVs, Health Worker, traditional healers and religious leaders, employers, friends, community leaders) Could you put them in order of influence from the most influential to the least influential? 9. What are the support services available for women during pregnancy and breastfeeding period other than health clinics (Why? who, what do they do and how do they support?) How are they helpful? 10. From your perspective, what motivates mothers to practice health behaviours such as breastfeeding and complementary feedings related to their children especially newborn and infants? 11. What are the constraints for these mothers to practice healthy IYCF behaviours? [Probe: sources of food, access to food, knowledge about food, traditional/cultural practices]

DG Community leaders & stakeholders

12. When people in general discuss or refer to breastfeeding what do you think they mean? [Probe: anything and everything related to breastfeeding, combined with complementary feeding] Constraints and supports 13. What is the overall situation of gender dynamics within a household in your community? Does it vary by cast and ethnic group? 14. Do you believe that women have the power to make their own decisions? [Probe. About their own health. Health of their children. How to care for their child. Choices of breastfeeding and complementary feeding] Does it vary by cast and ethnic group? Influential and trusted sources 15. Who are the most trusted sources of information regarding nutrition and health matters in this community? Media Habits 16. Do you have access to TV/Radio/cell phone/ newspaper/magazines/Internet? How often do you watch/ listen/read/ surf Internet and for how long? 17. How do you receive information â&#x20AC;&#x201C; news, attitude of your community, general communication with family, friends and colleagues? 18. [If said they use the internet or social media] How often do you use internet sites? How often do you text? 19. Do you have a cell phone? If yes, do you have a smart phone? Does any member in your household have a cell phone? Is it a smart phone? Aside from making phone calls, what else do you commonly use your phone to do? What other functions does your phone have that you don't use on a regular basis?

Thank you for your kind cooperation

DG Community leaders & stakeholders

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: Pharmacist (shopkeepers, vendors) I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to conduct a study on gender-issues related to breastfeeding and complementary feeding. II. Ground Rules We are interested in your opinions and feelings. There is no right or wrong answer. We need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose. I will also take some notes to help us in this task. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Name of pharmacy  Name of Respondent  Date of interview Background information Please note down the following information: Sex Age DG Pharmacists & Vendors

Caste/Ethnic group Education Years in service as pharmacist Location of shop (in market, stand alone) Position Duration at that pharmacy Mobile phone number Health Seeking Behaviour 1. What kinds of inquiries do you receive from your customers about childhood illnesses? (Rank them) 2. Do you receive questions about complementary foods? 3. Who usually ask about the complementary foods? [Husbands, wives, mothers-inlaw, HCW?] 4. Do you get training or support for your work? If not specifically mentioned, PROBE: have you received any training regarding breastfeeding or IYCF? If so, how helpful were these trainings? Who conducted the training? Constraints and measures 5. What do you see as prevailing feeding practices that put infants and young children at risk? 6. What problems do women face accessing health and nutrition services? 7. Which of these are related to gender norm issues? 8. I see some products in your pharmacy. What prevents your customers from accessing the products you carry? [cultural norms, costs, consumer does not know about them] 9. What are you views about nutrition for children? What are views of mothers and community on under nutrition? 10. What do you think would help the community better understand the value of breastfeeding and complementary foods? [Probe: training, communication, promotion] Observational research for Instant readymade complementary food in shops and markets and questions for value chain

DG Pharmacists & Vendors

•

Personal observation in the shop/market /pharmacies (take pictures of each of the following items): All o

Observe if product is on the shelf

Note price [Price per service or price per month in analysis]

Observe where product is placed in the shop – is it promptly displayed or hidden

Observe if there are Point of Purchase (POP) materials on display in the shop promoting the complementary foods? Low or high literacy? Memorable? Eye-catching? Understandable?

Product packaging – is it colorful? Memorable? Eye-catching? Lowliteracy or high-literacy? Instructions on how to use and prepare ICYF?

•

Discussion with shop owner (take pictures of vendor and customers in the shop or market) o

Ask shop owner if product sells – who buys it (man, woman, mothers-inlaw; socio-economic, caste ethnic group), how often do they purchase it, what do they pay/what is the price; do they come in and ask for it?

Has the owner had any academic detailing about the products? Someone to explain its value or worth?

Product – packaging? Colorful? Attractive? Easy to use? Instructions or directions (low literacy or high literacy)

What is the average time for the product on the shelf?

Who is the distributor and/or manufacturer?

Does the shop owner see this as a money return product (do they make a profit)

•

Content analysis o

Observe the content of any promotion related to IYCF – ads, print materials, POP, packaging, newspapers Thank you for your kind cooperation

DG Pharmacists & Vendors

GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD AND NUTRITION SECURITY IN NEPAL

Question Guide: Media (Reporters, Journalists) I. Introduction Welcome and thank you for taking time to participate in this discussion today. My name is........ I am working on behalf of RDN to study on gender equality and social inclusion for health specifically breastfeeding and infant and young child feeding. II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to provide frank comments that will improve our study. III. Confidentiality Everything that is said in today is confidential and only be used for this research purpose I will also take some notes to help us in this task. Attention to moderator: please self speak in audio the following:  District  VDC  Ward  Type of Media  Your job (reporter/journalist)  Specialty  Years as reporter/journalist  Name  Designation  Date of interview

Media DG

1. Who is/are your primary audience(s)? Men? Women? General Public? Officials? Business and Government Leaders? 2. What stories are of general interest to your audiences? – news, features, celebrity news and popular culture, health? To your editors? To you? 3. How engaged is your audience in gender-related issues? Nutrition and food security issues? Mothering and parenting? 4. How do your audiences between 18-35 get their information....are they reading newspapers? Or watching TV/listening to radio? Or using social media (Twitter, Facebook, Yahoo – web-based communication tools, texting)? 5. How do you get your information? Probe: newspapers, broadcast, internet, social media, individuals/influentials? 6. Do you have a social media account for your writing? 7. Who do you see as credible sources of information? 8. In order of priority what are the top five social issues within the community? 9. Is there attention or focus in the media on gender issues? good nutrition or food security practices? Breastfeeding or IYCF? 10. Specific to breastfeeding, when people talk about breastfeeding what do you think they are referring to? [Probe for specifics] 11. What do you believe are the positives of breastfeeding? [Probe: health to the child, health to the mother, child grows big and strong, cultural/social practice, it is done]; what are the negatives of breastfeeding? [Probe: takes too much time. Hard to do. Child is always hungry. Makes me unattractive.] 12. In order of priority with #1 being the main concern what are the key concerns and barriers of gender behaviour in your district? Does it vary with cast and ethnic group? 13. Do you feel that women (mothers) have the power to make their own decisions? [Probe. About health, about their children, about how to care for the children] 14. What is the overall situation of gender dynamics within a household in your district? Does it vary with cast and ethnic group? 15. Is there attention or focus in the media on gender issues and equality? In households or in work place? Is it encouraged or discouraged?

Media DG

16. Are you familiar with Infant and Young Child Feeding? Have you reported on it? Or has your paper/tv or radio station covered it?

Thank you for your kind cooperation

Media DG